OLDER AMERICANS MONTH CDCs Healthy Aging Program Dave Baldridge & Mario Garrett Advanced Care Planning and Emergency Preparedness Thursday May 5 th , 2011 Global Communication Center
Jan 15, 2016
OLDER AMERICANS MONTH
CDCs Healthy Aging Program
Dave Baldridge &
Mario Garrett
Advanced Care Planning and Emergency Preparedness
Thursday May 5th, 2011Global Communication Center
Overcoming Paradigm paralysis
End of Life Care for American Indians
Paradigm change
• Who’s an Indian elder?
“But she won’t talk about it.”
Barriers to “The Talk”
Tradition
Spirituality
Historical Trauma
Distrust of Medical System
Demographic changes
• We have met the future. It is here. It is us.
As a cohort . . .
• We are more . . .
Educated
AcculturatedWired
Computerized
Researchers have . . .
• Proposed a nursing model “built on a foundation of the ancient and venerable Native culture . . . (and) values presently utilized by Native Americans.”
• -- Struthers (2003)
Found that “some tribes do not talk about terminal illness for fear that talking about (it) will cause it to happen.”--Hepburn, 1995
Researchers have . . .
• Observed “that Western biomedical and bioethical concepts and principles often conflicted with traditional Navajo values and ways of thinking.”
Found 86% of Navajo elders interviewed considered advance care planning “a dangerous violation of traditional Navajo values . . .
--Carrese and Rhodes, 1995
National vs. Local Interest
Only 2 of more than 31,518 palliative care articles in 1995 substantively addressed AIANs, and . . .
70% of tribal health director survey respondents reported very high levels of interest on their medical teams --Spirit of Eagles program, IHS Provider, May 1995
In 1995 . . .
Four programs to watch
• Ft. Defiance, AZ Home Based Care Program
Cherokee Nation Home Health Services
Zuni Home Health Care Authority
UNM Palliative Care Program
Ft. Defiance Home-Based Care Program
THE CULTURAL TEAM MODEL
National rates for ADs
• National completion rate for advance directives—20-25%
Mostly those with terminal illnessor from higher socio-economic classes
Physician compliance is poor Kitzes, 2003
Ft. Defiance: Program history
• Ft. Defiance completion rate for • advance directives & DMPOAs
2010 ADs 85% DMPOAs 85%
1999 ADs 1% DMPOAs 4%
Ft. Defiance models
• PACE – Interdisciplinary team
Medicare Hospice BenefitCare focused in home, 6-month life expectancy
Care Transitions (Eric Coleman)Post-hospitalization transition
Ft. Defiance staff
– Embedded in community
Continuum of LTC . . . Know patients personally
Speak language
Cultural acceptability
Are empathetic
The KEY
– “It’s all about HOW you ask the questions . . .
and where you ask them . . .
and when . . .
and why.” Tim Domer
Cherokee Nation: The “Client-Directed” model
• Service Population
160,000 families (est. 85%) Southern Baptist
14 counties in NE Oklahoma
7,000 sq. miles
Staff of 220, includes 140 home health aides & personal care attendants
Cherokee Nation Home Health Program
• THE CLIENT-DRIVEN MODEL
Cherokee Nation: The “Client-Directed” model
• Cherokee Nation Outreach• Medicaid Advantage program
Cherokee Nation Home Health ServicesTribally owned & operated
Hospice of the CherokeesMC/MA certified in-home hospice
CNHHS: Program history
• Established in 1981
Realized “We were not different” than other programs in the state
Followed consultants’ advice
CNHHS: Program history
• “Caregivers were stressed out.”
Changed focus: personal care, homemaker chore services, and extended respite care.
CNHHS: Program history
• Available 24/7
Does not limit staff provision ofrespite or other home care.
CNHHS: The Key
Began asking one question: “What do you need?”
Threw all the models out
Zuni Home Health Care Agency:
THE TRIBAL-IHSPARTNERSHIPMODEL
Zuni Home Health Care Agency:
1,350 traditional Zuni & Navajo elders, most within 5 mi.
Two nurses, several home health aides
IHS hospital: 37 beds, 12 physicians, 3 PAs, 4 nurses—24 hr. ER, home visits
Zuni Home Health Care Agency
• The Keys
Respect/consistency with cultural beliefs
Incorporating EOL care into LTC continuum
Zuni Home Health Care Agency
• First inter-disciplinary team effort for Indian Country EOL
Served 76 patients in 9 years
90% of patients now complete ADs
Zuni Home Health Care Agency
• Most patients do not want to die at home
Success built on family members’ trust of home health care and hospital professionals.
UNMH Palliative Care Program
THE URBAN INSTITUTIONAL MODEL
• Albuquerque, pop. 500,000
UNMH Palliative Care Program
470 bed hospital, only Level 1 Trauma Center in state
Highest (10.3%) AI/AN admissions of any academic hospital in nation
UNMH Palliative Care Program
Patients by ethnicity
AI/AN 10.3% (Navajo, Pueblo, Apache, urban)
White 43%Hispanic 39%
43% of AI/AN patients die in hospital.
UNMH Palliative Care Program
Two-year-old Palliative Care Program
Two M.D.’s, nurse practitioner, part-time chaplain,Arts in Medicine team, occasional Fellows in gerontology or oncology.
High levels of expertise.
UNMH Palliative Care Program
“All our patients come to us in crisis, with urgent needs.”
“We don’t worry about ADs or paperwork. The trick is to set some Goals of Care, then get them translated into actual care.”
--Judith Kitzes, M.D.
UNMH Program Results
AI/AN patient preference for DNRs increased from 22% to 62%.
Family EOL meetings increased from 30% to 76%.
What they’re doing . . .
Using multi-disciplinary teams.
Consulting frequently.
Bringing no agenda, no assumptions.
What they’re doing . . .
Letting patient lead!
Hiring carefully for skills & personality.
“Empathy transcends barriers.”
Thank you!
Dave Baldridge<[email protected]>
National Indian Project CenterHealth Benefits ABCsCDC Division of Healthy AgingIHS Elder Care Initiative
IHS Emergency Services
• Staff function in the Office of the Director, Office of Clinical and Preventive Services
• Responsibilities:– Trauma Services– Emergency Medical Services– Physical Security– Emergency Management
• Outbreaks: flu epidemics, viruses, or other contagious diseases; food-borne outbreaks such as salmonella or E. coli.
• Natural Disasters: earthquakes, extreme heat, floods, hurricanes, landslides and mudslides, tornadoes, tsunamis, volcanoes, wildfires, and winter weather.
• Chemical / Radiation Emergency : industrial accident, or intentional such as in the case of a terrorist attack.
• Mass Casualties: fires, explosions, mass transit accidents such as train crashes or bridge collapses .
• Terrorism / Bioterrorism: Deliberate act of murder and destruction directed towards civilians. Deliberate release of viruses, bacteria, radiation, or other agents used to cause illness or death in people, animals, or plants. These agents can be spread through the air, water, contact, or in food.
Emergency Preparedness
Examples of published outbreaksamong American Indians
• 1982-1991 Community-acquired invasive group A strep infections in Zuni Indians
• 1991 Outbreak of gastroenteritis in Galena, Alaska
• 1993 Four Corners hantavirus outbreak• 2001 Tuberculosis outbreak on an American
Indian reservation, Montana• 2009 Syphilis Outbreak among American
Indians — Arizona
1964Anchorage AK, 9.2 Earthquake, 131 die the most violent earthquake in US historyNatural Disasters
1994, Northridge CA, 6.7 earthquake, 57 die
Natural Disasters
Research Priorities in Emergency Preparedness and Response for Public Health Systems
The Institute of Medicine (IOM) at the request of CDC’s Coordinating Officer for Terrorism Preparedness and Emergency Response (COTPER)
Four top-priority research areas:•enhancing the usefulness of training;•improving timely emergency communications;•creating /maintaining sustainable response systems; and•generating effectiveness criteria and metrics.
To Enhance:• Surveillance and Epidemiology• Preparedness and Response• Information Technology• Laboratory Capacityand • Stockpile of Vaccines and Antibiotics
(Strategic National Stockpile - SNS)
CDC Priorities
Copyright © 2005 by NAAEP. All rights reserved.
PHS Rapid Response Team
• Rapid Response Team (RRT) focuses on early detection of and rapid response to unusual disease occurrence; outbreaks or clusters of acute communicable disease, rare or unusual diseases of unknown etiology, or suspected BT.
PH Nurses
Epidemiologists
Public Health Laboratorians
Emergency Medical Staff
County Veterinarian
CDC Expert Panel on Evaluation ofSurveillance Systems
Dan Sosin, M.D., M.P.H.CDC/ Division of Public HealthSurveillance and InformaticsEpidemiology Program Office
• Claire Broome, M.D.CDC/ Office of the Director
• James W. Buehler, M.D.Center for Public Health Preparedness& Research, Dept of EpidemiologyRollins School of Public Health,Emory University
• Louise Gresham, Ph.D., M.P.H.San Diego Health and Human Services,Public Health Services et al.
BioSense Home PageSyndrome Specific SMART Score Results
SMART ScoreResults
For SpecifiedSyndrome
BioSense Health Indicators PageSyndrome-Specific Maps
Data SourceSpecific
Maps
Zip Code“Mouse Over”
DisplayZoom-In/Out
And Map Navigation
Tool
•MIGRATION•CLUSTERS•VULNERABILITY
Clusters• Rez : >60% of American Indian and Alaska
Native Clusters off Reservation• Hoods: African Americans• Towns: Asian Americans• Barrios: Latino Populations• Villages: White clusters
Caregiver Ratio IndexOne was to create an estimate of the number of frail elders—a factor determining the level of care needed. The second variable—the number of potential caregivers—partially defines the level of resources available to meet caregiving needs (Garrett, Baldridge, Benson et al; 2008).
Vulnerability
VulnerabilityNursing HomesTransportation issuesMulti generational householdsDisabilityIncarcerationGroup Quarters
Migration US Black 1995-2000
Migration US Latino 1995-2000
Migration US Asian 1995-2000
Migration AI/AN 1995-2000
DRAFT
Thank You
• Dave Baldridge– Tel: 505 239 4793– Email: [email protected]
• Mario Garrett– Tel: 619 992 5317– Email: [email protected]